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December 2015

The State of HIEs
By Mike Bassett
For The Record
Vol. 27 No. 12 P. 24

Moving from a noun to a verb has helped health information exchanges fine-tune their role in the HIT sphere.

With the passage of the HITECH Act in 2009, the federal government began the process of distributing more than $500 million to the states for the purpose of establishing health information exchanges (HIEs). Was that the correct approach? "When you think about information technology in a country as big as the United States, it's typically not going to involve something we are going to be building from the top down," says Doug Fridsma, MD, PhD, FACP, FACMI, president and CEO of AMIA.

One of the issues with programs such as meaningful use is that "we started with a model that was very much top down," Fridsma says, in the sense it involved the establishment of state or regional HIEs that would break down into smaller networks.

However, considering some of the tasks associated with exchanging health information, this approach has proven to be difficult. "It seemed a little complicated for a doctor who just wanted to send a prescription or a consultation to have to send it all the way to a state HIE and then all the way back down just to get it to the doctor across the street," Fridsma says. "So there came a recognition that this wasn't going to be a process in which one size fits all."

"We've seen lots of different models and lots of different ways of doing things, with lots of money spent, and we're seeing the things that stick and the things that are sliding down the wall," says Doug Dietzman, executive director of Great Lakes Health Connect, Michigan's largest HIE, who describes the early days of HIEs as being akin to throwing spaghetti against a wall to see whether anything would stick.

What seems to be sticking are organizations that meet particular demands within the market rather than those regional and state-based HIEs that are trying to be all things to all people. Successful HIEs "are meeting very specific needs that are tied to a value proposition so that organizations know what kind of value they are getting for the money they're spending," Dietzman says. "And those organizations that have been able to articulate why they exist and the value they are providing have tended to do a little bit better."

In the case of Great Lakes Health Connect, which was created by merging Michigan Health Connect and Great Lakes Health Information Exchange, the major focus was on providing value. "When we got started, the core problem that many of my hospital participants had was that doctors were putting EMR systems in their offices and they had 50 offices knocking on the door saying they wanted an interface," Dietzman says.

However, these hospitals didn't have the time, resources, or experience dealing with vendors to properly deal with that issue. Instead, Great Lakes Health Connect realized it could offer these services. "We took on the pain of building that integration and that is the value proposition we started with," Dietzman says.

Paul Steinichen, chief technology officer at Sandlot Solutions, which provides software support for organizations such as the MetroChicago HIE, considers HIEs to have evolved to the point where now they are thought of as a pathway to clinically integrated networks that allow for not only the exchange of patient records but also the meaningful use of those data.

"[HIEs are] really a subset of how we tackle the transition from fee-for-service to pay-for-performance, and how we create a network that allows us to let the right information follow the right patient, and [achieve] all the benefits associated with having good clinical information," he says. "We are getting HIEs to the point where they are just now understanding their value proposition and are clearly able to enunciate why someone would pay for this long term."

A Noun and a Verb
In the years leading up to President Barack Obama's election and the passage of the HITECH Act, it was clear that while the United States was spending billions of dollars on health care, it also was dealing with an HIT system that was woefully behind the times. The archaic health information infrastructure and the inability to repair it represented the very definition of a market failure.

According to Micky Tripathi, PhD, president and CEO of the Massachusetts eHealth Collaborative, this time period represented what he calls HIE 1.0: an era that focused on HIE the noun. "The old notion of HIE the noun is when you spoke of HIE, you spoke of an organization that would be in the center of solving market failures—and the idea was that there were a lot of market failures out there and no individual actor was going to solve them on their own," he says.

An HIE was going to solve this market failure by creating a data depository consisting of information drawn from a number of collaborating organizations. "We saw that one of its catchphrases was 'collect data once and use it for multiple purposes,'" Tripathi says. In so doing, an HIE would have to solve a wide variety of rich use cases through comprehensive interoperability that involved numerous complex legal, business, and technical requirements to support those use cases.

"And that was a huge lift for any organization trying to do it," Tripathi says. "Now fast forward to where we are now where HIE is a verb, so that when you speak of HIE, it's not that there's an organization that's pushing to be the substantiation of HIE activities. Instead, there are many ways of exchanging data through multiple different channels, and all of them sort of constitute HIE."

The HIE 1.0 world was "really swimming upstream against the market," he adds. "HIE now is much more demand driven—trying to meet market needs—and is, in part, why the idea of HIE as a noun has been blown apart."

Today, industry actors are conducting very particular types of exchanges to solve specific problems, Tripathi says. "But there is no sort of notion that I need to create an organization that's going to collect all the data and solve all those problems in one fell swoop, when the recognition was there that it was just too hard, took too much effort, and was too difficult to sustain," he says.

Hurdles to Clear
According to Steinichen, the major challenges facing HIEs are organizational, not technological. For example, contracts are complicated to negotiate, and every organization is going to have a multitude of players—compliance, security, and IT department managers—who are going have to be brought on board.

And once the organization piece is accomplished, HIEs have to push for adoption, which is another challenge. "A lot of early HIEs died on the vine because the value wasn't there and people stopped using them," Steinichen says. "Adopting the technology is key, and that adoption has to be tied to a clinical and business reason to do it. There has to be value, and you continually have to reinforce that value in order to have adoption at the right level in order to get the network effects, because ultimately HIEs are all about network effects."

When it comes to how HIEs handle the challenges associated with interoperability, Tripathi refers to the recent Government Accountability Office report "Electronic Health Records: Nonfederal Efforts to Help Achieve Health Information Interoperability," which cites the following major barriers:
• insufficient health data standards;
• variations in state privacy rules;
• difficulty in accurately matching the right records to the right patient;
• the costs and resources necessary to achieve interoperability goals; and
• the need for governance and trust among entities to facilitate sharing health information.

"A lot of the discussion always points to these five things," Tripathi says. "But I'm sanguine about where we are now and where we are going, because we are now very demand driven. Now you see more organizations that are just trying to solve the problems, and there are more ways of doing this.

"You are starting to see networks form," he continues, referring to Epic's Care Everywhere, which connects all Epic sites, and the eClinicalWorks Electronic Health Exchange (eEHX). "These are increasingly being used to drive millions and millions of transactions."

In addition to vendor efforts, the private sector is getting in on the act. "You have private HIE networks (like Great Lakes Health Connect) forming, and direct messaging networks, which are kind of like secure e-mail networks. And last, but not least, you still have some of the public HIEs out there," Tripathi says. "So what we are seeing now is that people have choices and if you are a provider you might have two, three, or four different ways of doing transactions, depending on your vendor."

What Does the Future Hold?
Dietzman, who presided over the merger of two Michigan-based HIEs to create Great Lakes Health Connect, believes the market will continue to see further consolidation. The industry's move toward a paradigm incorporating concepts such as care management, quality reporting, and analytics also promises to be a factor. "These are functions that are going to increasingly be on the plates of exchanges," he says. "And those that can morph with it to make it work will continue to grow."

Despite the challenges, Dietzman is bullish on the future of HIEs. "I think the opportunities are absolutely tremendous," he says. "The business is becoming more integrated and consolidated rather than being fragmented back into everyone staying in their own office, or their own health system, or their own health plan."

Tripathi says an examination of how other industries have evolved suggests what may be in store for HIEs over the next several years. For example, at one point electricity generation was localized, featuring small, disparate, and sometimes incompatible grids that somehow had to be bridged. "And the same thing was true with phone networks, which started from the bottom up with local phone exchanges," he says.

In each case, the problem was bridging the gap between these local grids or networks. "But once you reached a critical mass and you had a smaller number of networks that accounted for a large percentage of the customer base, then it made sense to get in a room and solve this bridging problem," Tripathi says. "At some point, there was enough of a critical mass to solve the bridging problem to make sure my network could talk to your network because it made my network more valuable at the end of the day. I suspect this is what is going to happen with health care."

Tripathi predicts the industry eventually may experience a situation in which networks such as Care Everywhere, eEHX, the CommonWell Health Alliance, and several others account for a large majority of the nation's HIE transactions. Should that come to fruition, he says it would be in these networks' best interests to sit down and solve any bridging problems—such as security, patient matching, pricing—that prevent true interoperability.

According to Fridsma, the biggest winners won't necessarily be providers or accountable care organizations. Rather, patients are most likely to benefit the most. "As we see more and more emphasis on patient engagement with things like precision and the Patient-Centered Outcomes Research Institute, we have to figure out how HIEs can engage the patient and provide them some value when it comes to how their data is used, how it is integrated, and how it is exchanged," he says. "We have to understand what the value proposition is for a patient to participate in these HIEs.

"For example," he adds, "if you have a patient who has school-aged children and is wondering whether they have their vaccination records up to date so they are ready for school, an HIE can provide some of these services and begin to demonstrate not just to physicians but to a wider population the value of sharing this information."

— Mike Bassett is a freelance writer based in Holliston, Massachusetts.